Pathology second opinions can be valuable even with no change in diagnosis

Patients are gradually becoming more aware of the value of second opinions on their pathology slides. When there is a significant change in the diagnosis, the decision to get a second opinion can be life altering and even life-saving. A recent example is the case of Rita Wilson, where the self-initiated second opinion of her breast biopsy resulted in a change in diagnosis from a non-invasive lesion to invasive cancer. What is less apparent is the potential value of a pathology second opinion even in cases in which there is no change in diagnosis, beyond its utility as an educational tool and as an opportunity to provide the patient with peace of mind. A recent case that I saw in consultation illustrates this point.

The patient was a 52-year-old woman with menorrhagia who underwent an endometrial ablation. At the time of the ablation, endometrial curettings were submitted, and a diagnosis of complex hyperplasia without atypia was made. This finding, coupled with her post-ablation status that would make it impossible to follow her for recurrence or progression with endometrial biopsies, resulted in a recommendation that the patient undergo hysterectomy.

I reviewed this case at the patient’s request. Although I agreed with the diagnosis of complex hyperplasia without atypia, I had several reasons to question its significance. This hyperplastic focus was polypoid, measured only about 3 mm, was found just beneath the endometrial surface, and made up only about 10 percent of the sample, with numerous other pieces of normal endometrium comprising the remainder. I correlated this finding with the patient’s recent transvaginal ultrasound, which noted the presence of an “endometrial cyst” of similar size. My conclusion was that this “cyst” was actually a small endometrial polyp that harbored a focus of complex hyperplasia without atypia (since polyps frequently contain cystic areas, it can be difficult to distinguish cysts from polyps using ultrasound).

In my correspondence with the patient, I made the following analogy to help drive home my opinion that a hysterectomy was not needed in her case: Imagine that your lawn had a pea-sized weed (your polypoid hyperplasia) that protruded slightly above the blades of grass (your endometrial lining). You mow the lawn (have a curettage), and the pea-sized weed is easily shaved off and located within the clippings (fragments of endometrium) that you discard (send to the lab). At this point, it is gone, but to make extra sure you set your lawn on fire and burn it to the ground (have an endometrial ablation). While it is possible that you didn’t fully burn your entire lawn and that some blades of grass may have survived here and there, the chances that anything is left of the pea-sized weed is pretty much zero.

I also researched the literature and found a recent study from Canada that demonstrated that ablation is a safe and effective long-term treatment for women who have non-atypical hyperplasia. This study implies that gynecologists in the United States who don’t perform ablations because of a prior diagnosis of non-atypical hyperplasia, or who perform hysterectomies when incidental non-atypical hyperplasia is found after ablation, are being overly cautious. I referenced this study in my report and provided the patient with the summary of its findings, which further helped her and her gynecologist make the decision to forgo hysterectomy.

So even though I agreed with the initial diagnosis, I was able to help the patient avoid what I viewed as an unnecessary hysterectomy by a) emphasizing that the focus of concern was tiny and superficial and had already been eradicated, b) correlating the pathologic with the clinical and radiologic findings, and c) supporting my position with recent medical literature.